Provider Demographics
NPI:1093120131
Name:BREVER, COURTNEY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:BREVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-656-7020
Mailing Address - Fax:320-656-7115
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-656-7020
Practice Address - Fax:320-656-7115
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093120131Medicaid
MNH400151571Medicare PIN